South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Medical Examiners

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Reynold Moore
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1 110 Centerview Dr Columbia SC P.O. Box Columbia SC REQUIREMENTS AND INSTRUCTIONS FOR A LICENSE TO PRACTICE AS A LIMITED RESPIRATORY CARE PRACTITIONER The Forms contained in this packet may not be mailed in with payment and processed as a regular application. They are specifically to be used with the online electronic application where payment is remitted online. READ REQUIREMENTS CAREFULLY BEFORE COMPLETING APPLICATION. APPLICATION FORM An application will be considered as incomplete until all of the following information is submitted: Submit with your application: Submit your application by making the $40 application fee via Visa, Mastercard or E-Check. A returned check fee of up to $30, or an amount specified by law, may be assessed on all returned funds. Upload a copy of your valid Driver s License, State Issued ID, Passport or Military ID Upload a copy of your social security card Upload legal documentation for name change Upload Notarized Signature Form with 2x2 professional photo Upload Verification of Lawful Presence Affidavit of Respiratory Care Program Director Have submitted directly to the Board office address above from the issuing agent: License Verification from each state medical board that you are currently or have ever been licensed in. 3 Reference for Respiratory Care Practitioner Forms CRIMINAL BACKGROUND CHECK (CBC): An applicant for a license to practice medicine in South Carolina shall be subject to a criminal history background check as defined in Section of the Medical Practice Act. The Board will send you instructions on how to have your fingerprints processed once your application is received. PROCESSING TIME Applications having all information with no identifiable problems will be expeditiously processed. Incomplete applications or problematic applications will require additional processing time.

2 110 Centerview Dr Columbia SC P.O. Box Columbia SC AFFIDAVIT OF RESPIRATORY CARE PROGRAM DIRECTOR (Complete only if presently a student) This is to verify that is a student in the (Name of Applicant) Respiratory Care Program at (Name of School) which is a program approved by the Joint Review Committee for Respiratory Care Education and should graduate on:. Sign: Respiratory Care Program Director Date: Sworn to and subscribed me this day of, 20. Notary Signature: Print name: Notary Public for the State of: Commission Expiration Date: SEAL RCP Affidavit (Rev. 5/2016) Page 1 of 1

3 P.O. Box Columbia, SC REFERENCE FOR RESPIRATORY CARE PRACTITIONER APPLICANT Make copies or provide a link of this form to each reference. Individuals giving a reference should know you in a professional capacity. They cannot be related by blood or marriage. Applicant s Name: Dates of Association: Relation to Applicant: Describe the applicant's moral character and fitness (attach a separate sheet of paper if necessary) Moral Character: Professional Competence: Interpersonal Relations with Others: Signature Date Print Name Daytime Phone Number Street Address City State Zip RCP Reference Form (06/2015) Page 1 of 1

4 P.O. Box Columbia, SC NOTARIZED SIGNATURE AFFIDAVIT Certification: I, being duly sworn, depose and say that I am the person described and identified, and that I am the person named in the documents presented in support of this application. By filing this application, I hereby authorize and consent to an investigation of my fitness and qualifications to practice as a Respiratory Care Practitioner in South Carolina. I hereby authorize all hospitals, medical institutions or organizations, my references, personal physicians, employers (past and present), and all governmental agencies and instrumentalities (local, state and federal) to release to this licensing Board any information, files or records requested by the Board for its evaluation of my professional, ethical and other qualifications for licensure in South Carolina. I hereby release, discharge and exonerate the State Board of Medical Examiners of South Carolina, its agents or representatives and any person or organization furnishing information from any and all liability of every nature and kind arising out of the furnishing of documents, records or other information, or arising from the investigation made by the State Board of Medical Examiners of South Carolina. I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind, and I declare that all statements made by me herein are true and correct. Should I furnish any false or incomplete information in this application, I hereby agree that such an act shall constitute the cause for denial or revocation of my license to practice medicine in South Carolina. Further, if licensed, I agree to keep the Board informed of any future changes in my address. I hereby authorize the Board of Medical Examiners of South Carolina to utilize my Social Security Number in making reports to the Federation of State Medical Boards Physician Data Center for compilation of information about applicants and licensees in order to coordinate licensure and disciplinary activities between the individual States licensing boards. Signature of Applicant Print Name of Applicant Subscribed and sworn to before me this day of 20. Tape a recent 2 x 2 Passport Photo (less than 6 months old) Notary Signature: Print Name: Notary for the State of: My Commission expires: (Notary Seal)

5 STATE OF SOUTH CAROLINA DEPARTMENT OF LABOR, LICENSING AND REGULATION VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES AFFIDAVIT OF ELIGIBILITY Pursuant to Section , et seq. of the South Carolina Code of Laws (1976, as amended), the Department of Labor, Licensing and Regulation must verify that any person who applies for a South Carolina license is lawfully present in the United States. Complete and sign this affidavit of eligibility. The information provided is subject to verification. Section A: LAWFUL PRESENCE in the United States. The undersigned, of (Print clearly First, Middle, and Last name) (Home Address, City, State, and Zip Code) being first duly sworn deposes and states as follows: Check only one box: 1. I am a United States citizen; or 2. I am a Legal Permanent Resident of the United States eighteen years of age or older; or 3. I am a Qualified Alien or non-immigrant under the Federal Immigration and Nationality Act, Public Law , eighteen years of age or older, and lawfully present in the United States. 4. Other: Please submit any documentation that supports this status. Date of Birth: _ Alien Number: _ I-94 Number: (If you checked number 2, 3, or 4 you must attach a copy of your immigration documents. See instruction sheet for a list of accepted immigration documents.) Section B: ATTESTATION. I understand that in accordance with section of the South Carolina Code of Laws, a person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall, in addition to other sanctions imposed by this State or the United States, be guilty of a felony, and upon conviction must be fined and/or imprisoned for not more than 5 years (or both). I understand that the representations made in this Affidavit shall apply through any license(s) or renewals issued, and that I shall have an affirmative duty to immediately advise the Department of Labor, Licensing and Regulation of any change of my immigration or citizenship status. I swear and attest the information contained herein is true and correct to the best of my knowledge. I understand that under South Carolina law, providing false information is grounds for denial, suspension, or revocation of a license, certificate, registration or permit. Signature of Affiant SWORN to before me this day of, 20 Notary Signature Print Name Notary Public for My Commission Expires: Rev:

6 INSTRUCTION SHEET FOR COMPLETING AFFIDAVIT OF ELIGIBILITY CHECK box 1: If you are a United States Citizen by birth or naturalization CHECK box 2: If you are a Legal Permanent Resident and you are not a U.S. Citizen, but are residing in the U.S. under legally recognized and lawfully recorded permanent residence as an immigrant. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. CHECK box 3: If you are a Qualified Alien. You are a Qualified Alien if you are: An alien who is lawfully admitted for residence under the INA. An alien who is granted asylum under Section 208 of the INA. A refugee who is admitted to the United States under Section 207 of the INA. An alien who is paroled into the United States under Section 212(d)(5) of the INA for a period of at least 1 year. An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect prior to April 1, 1997) or whose removal has been withheld under Section 241(b)(3). An alien who is granted conditional entry pursuant to Section 203(a)(7) of the INA as in effect prior to April 1, An alien who is a Cuban/Haitian Entrant as defined by Section 501(e) of the Refugee Education Assistance Act of An alien who has been battered or subjected to extreme cruelty, or whose child or parent has been battered or subject to extreme cruelty. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. ACCEPTED IMMIGRATION DOCUMENTS: Unexpired Reentry Permit (I-327) Permanent Resident Card or Alien Registration Receipt Card With Photograph (I-551) Unexpired Refugee Travel Document (I-571) Unexpired Employment Authorization Card Which Contains a Photograph (I-766) Machine Readable Immigrant Visa (with Temporary I-551 Language) Temporary I-551 Stamp (on passport or I-94) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport I-20 (Certificate of Eligibility for Nonimmigrant, F-1, Student Status) DS2019 (Certificate of Eligibility for Exchange Visitor, J-1, Status) Rev:

CPA LICENSURE APPLICATION BY RECIPROCITY ELECTRONIC APPLICATION FORMS AND INSTRUCTIONS

CPA LICENSURE APPLICATION BY RECIPROCITY ELECTRONIC APPLICATION FORMS AND INSTRUCTIONS South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Accountancy 110 Centerview Dr. Columbia SC 29210 P.O. Box 11329 Columbia SC 29211-1329 Phone: 803-896-4770 Contact.Accountancy@llr.sc.gov